MAC CLAIMS DOCUMENTATION

Documenting Pertinent Information to support mac claims

CMS MAC DOCUMENTATION REQUIREMENTS

• “Documentation maintained in support of administrative claims must be sufficiently detailed to determine whether the activities are necessary for the proper and efficient administration of the state plan. Simply checking a box on a time study form does not facilitate independent validation of the sample results.” (CMS Medicaid School-Based Administrative Claiming Guide, May 2003, Section V., A., pg. 37)

DOCUMENTATION GUIDANCE:

• Describe only the actions performed in support of the claimable MAC activities reported. Do NOT include explanations of actions performed in support of non-claimable activities.
• Documentation in support of C1.1 – Referral for a Medicaid-covered service, C1.2 – Care coordination of a Medicaid-covered service, or C1.3 – Monitoring/Follow-up of a Medicaid-covered service, must indicate the activity was to an OHP provider. NOTE: EXCEPTION If the activity occurs before the final referral for or coordination of care for a Medicaid covered health service as part of gathering history/paperwork/information in advance.
• Utilize activity descriptions from the MAC coding guide to aid in providing clear and concise documentation which align with MAC codes reported. Use action verbs to describe activities such as, referred, coordinated, monitored, followed-up, gathered, assisted, etc.
• Do NOT lump together description of activities that fall under two or more different MAC activity codes.
• Use ink or type on supporting documents
• Exclude names of students and their families

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DOCUMENTATION BEST PRACTICES – B1.1

NO

• B1.1 - Handed out brochures. Referred Students.
• Handed out what type of brochures? Referred students for what?
• B1.1 - Called parents to inform about results of eye visions checks (6 parents). 3 out of 6 parents referred to OHP.
• Following up after a Medicaid covered eye exam to discuss results is a C1.3 activity. The second activity for referral to Medicaid (OHP) is a covered activity under B1.1. Which activity took the predominant time?

YES

• B1.1 - Informed parent of services covered under OHP and how to access them.
• B1.1 – Discussed services covered by OHP with a student needing dental care. Provided him with OHP literature identifying covered services and a contact number.
• B1.1 - Informed a child/family on how to effectively access, use, and/or maintain participation in Medicaid/OHP.

DOCUMENTATION BEST PRACTICES – B1.2

NO

• B1.2 - Assisted family in Trillium referral packet, for girl with separation anxiety.
• This example documentation provides no indication of what Trillium is (an OHP provider) and that the referral packet for Trillium includes the application for OHP.
• B1.2 – Assisted student in completing referral forms for Student based health center.
• This example provides no indication that the referral forms for the Student Based Health Center include the application for OHP.

YES

• B1.2 - Assisted parent to apply for and complete OHP application.
• B1.2 – Assisted the student/family access, apply for and/or complete the Medicaid/OHP application (includes transportation and translation related to the application and gathering appropriate information).

DOCUMENTATION BEST PRACTICES – B1.3

NO

• B1.3 - Checked status of OHP and Free and Reduced lunch eligibility.
• This example documentation includes conflicting information and includes information that supports non-claimable activities. Free and Reduced Lunch is not a covered MAC activity and is coded B2. Two activities occurred here which must be recorded under separate codes. Report the activity that took the predominant portion of time.

YES

• B1.3 - Checked OHP status of a student.
• B1.3 – Checked student’s OHP status.

DOCUMENTATION BEST PRACTICES – B1.4

NO

• B1.4 – Coordinated medical services for a pregnant teen, including WIC services.
• This example documentation includes conflicting information and includes information that supports non-claimable activities. WIC is not a covered MAC activity and is coded B2. Two activities occurred here which must be recorded under separate codes. Record the predominant activity that occurred each 15 minutes.

YES

• B1.4 - Talked to a parent about availability of OHP and well-baby programs.

DOCUMENTATION BEST PRACTICES – C1.1

NO

• C1.1 - Gathered information through meeting with another teacher and high school counselor to prepare referral for mental health/substance abuse evaluation for services covered by Medicaid/OHP.
• Documentation is not brief.
• Example: Gathered information in advance of a potential referral for Medicaid covered mental health services.
• C1.1 - Talked about Counseling Services offered in school by Trillium with student.
• Documentation does not indicate what/who Trillium is and that they are an OHP enrolled Mental Health Provider.

YES

• C1.1 - Gathered information in advance of referral for mental health services to a Medicaid provider.
• C1.1 - Referred student to OHP provider for mental health services.

DOCUMENTATION BEST PRACTICES – C1.1

NO

• C1.1 - Called parent to inquire if student was on OHP, if he has seen a dentist about his tooth and if he had vision issues. Student is on OHP but has not been to the dentist because they couldn’t find a dentist that takes OHP. He has a prescription for glasses but doesn’t have any because they broke. I instructed them to call our school nurse and she would help them with services.
• Numerous activities occurred here, of which several may be claimable under different codes depending on what activities took the predominant portion of time. Separate the documentation of activities appropriate to code and predominant activity.

YES

• C1.1 - Gathered information in advance of referral for dental and vision services to a Medicaid provider.

DOCUMENTATION BEST PRACTICES – C1.2

NO

• C1.2 - Met with student’s parents and student regarding reports received about reported unusual, at-risk behaviors and statements made by the student, and the student’s mental health. Recommended that student receive medical and mental health assessments by a licensed healthcare professional, and possible medical care and counseling needs.
• Documentation although thorough, could be more concise. Example: Referral to an OHP provider for mental health services.

YES

• C1.2 - Coordinated delivery of mental health services for a student to a Medicaid provider.

DOCUMENTATION BEST PRACTICES – C1.3

NO

• C1.3 - Remind student to go to nurse for meds.
• A reminder alone may be too brief an activity to be considered the predominant portion of a 15-minute period.
• C1.3 - Reviewing electronic medical records in Avatar of various students to prepare for the attendance in school.
• Based on how the documentation is written, it appears the activity is to support verifying school attendance, which is not a claimable MAC activity and would be coded A.

YES

• C1.3 - Monitoring the medical component for a student’s 504 plan.
• C1.3 - Provided follow-up contact to ensure student received prescribed vision services from a Medicaid provider.

DOCUMENTATION BEST PRACTICES – C1.4

NO

• C1.4 - Participated in Train the Trainers.
• What type of train the trainers? Provide a description that supports the claimable activity coded.

YES

• C1.4 – Participated in MAC training to identify claimable activities.
• C1.4 - Participated in a training to recognize/identify signs and symptoms of medical conditions covered by Medicaid/OHP.
• C1.4 - Participated in MAC survey in asking the coordinator for clarification to code meanings and services but did not include filling out the actual survey.
• C1.4 Participated in a training on what services are covered by OHP and on the referral process for applying for OHP.

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DOCUMENTATION BEST PRACTICES – D1.1

NO

• D1.1 - Medicaid/OHP Transportation Info gathering/collaboration Medicaid transport provided to support.
• Confusing and incomplete documentation.
• D1.1 – Spoke with parent regarding needs, then called taxi service to arrange for them to be transported to the Children’s Memorial Hospital for emergency medical services for their child.
• Documentation could be more concise. Example: Arranged Taxi service to transport student to Children’s Memorial Hospital for emergency medical care.

YES

• D1.1 – Informed parent of OHP covered transportation options as part of post-op plan for student receiving surgery.
• D1.1 – Arranged for transportation services for a child to obtain Medicaid-covered Nursing services as per their IEP.
• D1.1 – Arranged taxi services for family to access OHP covered emergency medical care.

DOCUMENTATION BEST PRACTICES – D1.2

NO

• D1.2 - Provided translation services for AGR’s Mom to access necessary care needed prior to IEP meeting.
• Documentation is confusing by indicating care is being arranged for the mother. SBHS MAC covers services to the child. What type of care? Was it Medicaid covered health care?
• D1.2 – Spoke with school regarding who could provide translation services for a Spanish speaking family that cannot understand medical needs of student.
• Could be more concise. Example: Arranged Spanish translator to interpret medical needs of student.

YES

• D1.2 – Provided translation services for parent to understand change in Medicaid–covered services identified on the IEP.
• D1.2 – Provided translation services to aid in understanding OHP covered vision services.

DOCUMENTATION BEST PRACTICES – E1.1

NO

• E1.1 – Talked with admin regarding translation of documents on paper and the ability to send emails in Spanish so all families receive health info.
• Developed strategies on communicating with Spanish speaking families to provide information in Spanish about available Medicaid covered health services.

YES

• E1.1 – Developed strategies with staff to increase access to OHP mental health services.
• E1.1 - Developed strategies and policies to assess school dental/mental health programs.

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DOCUMENTATION BEST PRACTICES – E1.2

NO

• E1.2 - Working with outside agency on substances abuse services.
• Documentation is incomplete. Documentation must include what the target audience is and why?

YES

• E1.2 – Collaborated with outside agency to improve the availability of substance abuse services to k-12 students.
• E1.2 - Conferred with community OHP provider to improve the referral process for mental health, including revising referral protocol.

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DOCUMENTATION BEST PRACTICES – E1.3

NO

• E1.3 – Discussion with middle school and SPED administrators about the importance of monitoring & recording behavioral issues seen with students with high functioning ASD as well as other students with ASD.
• Documentation could be more specific. Example: Developed strategies to improve the monitoring/recording of behavioral actions of ASD students.

YES

• E1.3 – Collaborated with outside agency regarding collection and data monitoring of behavioral concerns for students with ASD.
• E1.3 – Monitored OHP covered school health screening process to assess effectiveness and make recommendations for improvement.

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